Competencies for Disaster Mental Health

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R. V. King (*). Department of Emergency Medicine, EMS Division, University of. Texas Southwestern Medical Center, MC8890, Dallas, TX 75390,. USA e-mail: ...

Curr Psychiatry Rep (2015) 17:14 DOI 10.1007/s11920-015-0548-2

DISASTER PSYCHIATRY (CS NORTH AND B PFEFFERBAUM, SECTION EDITORS)

Competencies for Disaster Mental Health Richard V. King & Frederick M. Burkle Jr. & Lauren E. Walsh & Carol S. North

# Springer Science+Business Media New York 2015

This article is part of the Topical Collection on Disaster Psychiatry

groups within particular professions or specialties. Competency sets specifically for disaster mental health professionals are lacking, with the exception of one set that focused only on cultural competence. The identified competency sets provide guidance for educators in developing disaster mental health curricula and for disaster health workers seeking education and training in disaster mental health. Valid, criterion-based competencies are required to guide selection and training of mental health professionals for the disaster mental health workforce. In developing these competencies, consideration should be given to the requirements of both domestic and international disaster response efforts.

R. V. King (*) Department of Emergency Medicine, EMS Division, University of Texas Southwestern Medical Center, MC8890, Dallas, TX 75390, USA e-mail: [email protected]

Keywords Competencies . Disaster medicine . Disaster health . Disaster mental health . Competency-based education . Professionalization

Abstract Competencies for disaster mental health are essential to domestic and international disaster response capabilities. Numerous consensus-based competency sets for disaster health workers exist, but no prior study identifies and discusses competency sets pertaining specifically to disaster mental health. Relevant competency sets were identified via MEDLINE, PsycINFO, EBSCO, and Google Scholar searches. Sixteen competency sets are discussed, some providing core competencies for all disaster responders and others for specific responder

F. M. Burkle Jr. Harvard Humanitarian Initiative, Harvard University, Cambridge, MA, USA e-mail: [email protected] F. M. Burkle Jr. Woodrow Wilson International Center for Scholars, Washington, DC, USA L. E. Walsh Henry M. Jackson Foundation for the Advancement of Military Medicine, National Center for Disaster Medicine & Public Health, 11300 Rockville Pike, Suite 1000, Rockville, MD 20852, USA e-mail: [email protected] C. S. North VA North Texas Health Care System, Dallas, TX, USA C. S. North Division of Trauma and Disaster, University of Texas Southwestern Medical Center, Dallas, TX, USA e-mail: [email protected]

Introduction Core capabilities have been identified that define the elements by which the USA and communities throughout the nation may assess, develop, and maintain their readiness to address all plausible threats and hazards through effectively performing critical functions and tasks for the missions of prevention, protection, mitigation, response, and recovery [1]. A competent workforce, one in which individuals and teams have the necessary skills and training in the discipline of disaster health, is considered essential to public health core capabilities such as mass care [2]. A disaster health discipline must be built upon defined multidisciplinary competencies applicable to disaster and humanitarian workers in diverse settings domestically and internationally [3]. Competencies,

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ideally, describe the characteristics of workers that enable effective and/or superior performance in a job, role, or situation according to specified performance criteria [4]. These characteristics include knowledge and skills, but may also include a person’s motives, traits, self-concept, and behavior [5–8]. Disasters superimpose additional layers upon the everyday competency requirements of workers. Knowledge specific to disasters, such as knowledge of the National Incident Management System [9], is essential. Yet emergency response leaders and experienced disaster workers have recognized that not all knowledgeable people function well in disasters [6, 10]. For example, disasters demand of workers considerable flexibility and the ability to abruptly shift from their usual ways of practicing. Some workers are better able than others to make such adjustments and to perform their disaster roles effectively. The Institute of Medicine acknowledges and emphasizes the important distinction between knowledge and performance by including in all of its reports in recent years a quotation of Johann Wolfgang von Goethe: BKnowing is not enough; we must apply. Willing is not enough; we must do.^ [11, 12]. An effective disaster health workforce must have individuals and teams who possess a diverse set of competencies and who consistently perform their assigned roles well. The Pandemic All-Hazards Preparedness Act (PAHPA) of 2006 [13] mandated the establishment of competency-based curricula to guide the development of a public health workforce prepared to meet the needs of the nation and its communities in the event of disasters and other emergencies. This state of readiness was to be accomplished in part by making use of existing education and training programs and creating new programs as needed to develop and maintain a competent workforce. In 2007, Homeland Security Presidential Directive (HSPD)-21 [14] acknowledged the unique principles involved in carrying out the responsibilities of public health and medicine within the context of disasters and called for the establishment of a discipline of disaster health. A diversity of health care providers competent in this discipline would perform the essential capabilities of caring for survivors, attending to both their physical and mental health needs. Disaster mental health has become increasingly recognized as an essential function in disaster preparedness and response, particularly with incidents involving terrorism, which has been characterized as an intentional attack on a nation’s mental health [15–18]. Federal all-hazards planning guidance for fulfilling the requirements of an effective disaster mental health response were identified in 2003 through a collaborative assessment of state disaster mental health plans by the Center for Mental Health Services within the Substance Abuse and Mental Health Services Administration (SAMHSA) in collaboration with the National Association of State Mental Health Program Directors (NASMHPD) [19]. This guidance was intended to compliment and augment

FEMA’s earlier, more general, disaster planning guidance for states [20] by adding information specific to mental health care. It also compliments national standards for state and local planning of public health preparedness capabilities [2]. These documents describe the larger context in which disaster mental health competencies are needed and are likely to be operationalized. Various sets of competencies have been created in attempts to describe the knowledge and skills needed by segments of the disaster health workforce that are pertinent to core capabilities. Existing competency sets have targeted various workforce segments or audiences including all disaster health responders (core), specific professions (e.g., public health workers, physicians, nurses, or EMTs), and organizations (e.g., hospital workers). Some competencies emphasize specific topics or focal areas, such as disaster mental health as a focal area for all disaster health workers [21•, 22]. In the literature, several articles have described existing disaster worker competency sets [5, 21•, 22], though none has provided an overview of competencies specific to disaster mental health. The development of a disaster health workforce competent to address matters of mental health in disasters requires welldefined competencies that can guide selection of personnel and the provision of comprehensive and effective training. The training to be guided by these competencies includes both the core training of all disaster workers to prepare them to address the ubiquitous mental health needs of disaster survivors while also caring for themselves and coworkers and the more specialized training needed to prepare those in the various mental health professions to work effectively in disaster settings that require significant departures from everyday work practices. This report identifies, describes, and discusses the existing competency sets pertinent to disaster mental health.

Methods Searches of MEDLINE, PsycINFO, and EBSCO databases were conducted using the keywords Bcompetencies AND (disaster OR emergency OR preparedness) AND (medicine OR health OR behavioral OR psychosocial OR psychological).^ Other Web searches were conducted using Google and Google Scholar. Articles or other documents containing competency sets or reviews of competencies were selected for further review, and additional sources were found among the citations contained within these documents. The competency sets included in this report are those that addressed mental health, psychosocial, psychological, or behavioral health, whether being the primary focus or part of a broader set of competencies. A previously developed classification scheme [21•] was used to categorize the identified competency sets in terms of the breadth of intended target audience.

Focus 7 domains of competencies at 6 cognitive levels [24]; 19 core competencies for 3 broad personnel categories—leader, informed worker/student, and practitioner

11 competencies and 36 subcompetencies. Target audiences within disaster health discipline defined

General and bioterrorism-specific emergency preparedness competencies for all public health workers. Categories include preparedness/planning, response/ mitigation, and recovery/evaluation. Intended use—planning, training, and assessment

25 consensus-based competencies for public health nurses by 3 disaster phases—prevention, response, and recovery Prevention, preparedness, response, and recovery competencies aligned with public health capabilities and existing competency models including Council on Linkages competencies. Competencies in 3 areas—foundational (core competencies for PH (not disaster); generic health security or emergency core competencies (e.g., NIMS); and positionspecific or professional competencies (e.g., PH nurse, environmental health, PH law, applied epidemiology, informatics). Adds 18 competencies under 4 domains to existing competency sets Competencies to guide education and training for emergency preparedness and disaster response

Audiencea Core (all public health and medical disaster responders)

Core (all public health workers and other workers who may respond in a public health emergency under ESF-8 [25, 26])

Profession (public health) Focal Area (bioterrorism); All public health workers; some competencies specific to leaders, professional, technical, and support staff

Profession (public health nurses)

Profession (public health); targets mid-level public health workers

Profession (perinatal and neonatal nurses)

Subbarao et al. 2008 A consensus-based educational framework and competency set for the discipline of disaster medicine and public health preparedness [23]

Walsh et al. 2012 Core competencies for disaster medicine and public health [22]

CDC 2002 Bioterrorism and emergency readiness: competencies for all public health workers [27]

Polivka 2008 Public Health Nursing Competencies for Public Health Surge Events [28]

ASPH 2010 Public Health Preparedness & Response Core Competency Model (Final Model version 1.0) [29, 30]

Jorgensen 2010 Emergency preparedness and disaster response core competency set for perinatal and neonatal nurses [31]

Competency sets in which mental health is not the primary focus

Competency set

Table 1

Clinical and public health assessment and intervention •Knowledge of potential mental health consequences in pregnant women affected by public health emergencies and disasters •Identify bereavement nurse counselors

•Knowledge of psychological sequelae of disasters •Skills in clinical assessment and management mental health conditions manifested by all ages and populations in a disaster or public health (PH) emergency •Common mental health consequences for all ages and populations affected by a disaster or public health emergency •Need to monitor and mitigate effects of health emergencies on responders and their families •Recovery/evaluation—recognize and treat psychological impact of event on victims and health care professionals •Response/mitigation—handle human remains appropriately, address safety, psychosocial, and forensic requirements •Recovery/evaluation—ensure ongoing support for the psychological impact on families of victims •Response—identify psychosocial needs of individuals, families, and communities (including responders) •Recovery—assess psychosocial impact of the event •Manage behaviors associated with emotional responses in self and others •Apply principles of crisis and risk communication •Report unresolved threats to physical and mental health through chain of command

Mental health

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Classification scheme from Walsh et al. [21•]

Profession (acute care medical professionals). Schultz 2012 Development of National Standardized All-Hazard Core Competencies for Acute Care Physicians, Nurses, and EMS Professionals [33].

Results

a

Presents a competency model as a framework of core knowledge, skills, and abilities for a student to demonstrate upon completing a master’s degree or graduate certificate in public health preparedness and response at an ASPH-member school of public health Competencies needed in common by various acute care professions. Example given that is linked to Subbarao core competencies Profession (graduate-level faculty at ASPH-member Schools of Public Health) ASPH 2011 Master’s-Level Public Health Preparedness and Response Competency Model [32]

•Mass fatality management of mothers and infants •Needs of vulnerable populations •Potential psychosocial consequences on public health workers and community members •Principles of crisis and risk communication •Strategies to promote community resilience Domain—psychosocial issues Competency—responding appropriately to stress-induced behaviors in victims and responders Performance objectives •Identify common stress reactions and acute and long-term consequences of disaster exposures •Identify need for psychological first aid (PFA) and steps to request PFA for those in need

Focus Audiencea Competency set

Table 1 (continued)

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Mental health

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Sixteen relevant competency sets were identified in this study. Some competency sets were intended for all disaster responders (i.e., core competencies), while others targeted specific groups of responders, i.e., members of specific professions. Only one competency set provided disaster mental health competencies specifically intended for mental health professionals, and its focus was limited to cultural competence. The depth to which disaster mental health is addressed varies across these competency sets. Eight sets were not primarily focused on mental health but were instead geared toward identifying broader knowledge and skills relevant to disaster health, mainly to guide education and training for a variety of disaster responder audiences (Table 1). The other eight sets were specifically mental health focused (Table 2). In the former group (disaster health in general), two sets were categorized as core, being intended for all disaster health responders, and six were targeted at specific professions that would normally be represented in a disaster health workforce. In the latter group (mental health focused), six sets were categorized as core with a focal area of mental health, and two sets targeted specific professions. The competencies for professions outside of mental health resemble the core disaster health competencies. The one set of competencies specific to mental health professionals had a focal area of cultural competence. Two competency sets of particular importance for disaster health are Subbarao et al. [23] and Walsh et al. [22]. These competency sets were aimed at the broadest audience within the disaster health discipline and reflected a consensus of a wide group of experts, resulting in a robust set of consensusbased baseline core competencies for the discipline of disaster health (alternatively called disaster medicine and public health). Only a few competencies within these competency sets are specific to mental health, such as knowledge of the psychological sequelae of disasters, the ability to assess and manage mental health issues, and the ability of responders as care givers to attend to their own mental health needs. These and other competency sets that are specific to public health professionals [2, 27, 28] also contain competencies to do with family concerns, such as bereavement, and community level concerns, such as risk communication and the promotion of community resilience. Competency sets that are focused specifically on mental health naturally provide considerably more details relevant to what responders need to know concerning disaster mental health needs and care. Examples of this detail include principles of psychological first aid; differentiating normal distress from pathological stress responses; use of the Haddon matrix in planning to prevent and mitigate injuries; cultural considerations and vulnerable populations in mental health response,

•Understand psychophysiology of fear and terror and related behavioral responses and psychopathology •Apply Haddon Matrix to disaster mental health planning •Recognize vulnerable populations and how they may be affected •Understand the cultural context of mental health responses to disasters and terrorism •Differentiate normal from pathological responses •Assessment, intervention, and referral for appropriate treatment •Understand mental health interventions and their appropriate use •Know community mental health resources and how to access them •Understand principles of self-care for responders 5 consensus core competencies for mental, psychosocial, and behavioral health; sequelae of disasters for emergency preparedness and response Key mental health care concepts •Effective communication •Needs assessment •Action planning •Care of patients, self, and colleagues Knowledge of key terminology and concepts: •Biopsychosocial and cultural manifestations of stress •Effects of trauma and losses •Appropriate interventions Skills: •Communication •Assessment •Action planning •Intervention Minimum responses are described •Assessment of mental health and psychosocial support •Include specific psychological and social considerations in provision of general health care •Provide access to care for people with severe mental disorders •Protect and care for people with severe mental disorders and other mental and neurological disabilities living in institutions •Collaborate with local, indigenous and traditional health systems •Minimize harm related to alcohol and other substance use Learning objectives, topics, and recommended learning resources based on previously identified best Provide a competency framework development of training, curricula, and evaluation. Identifies 14 mental health competencies and related knowledge, skills, and attitudes for health care providers

Funded by CDC and ASPH. Intended to guide training and equip workforce for psychological needs of disaster survivors and responders. Involved exemplar group from Centers for Public Health Preparedness. Systematically reviewed existing training programs. Provides guiding principles for implementing the competencies

Presents a layered system of mental health and psychosocial support functions (MHPSS)

Core (all health care providers; multiple professions) focal area (mental health)

Core (public health and other disaster health workers); focal area (mental health)

Core (all humanitarian health workers) focal area (mental health and psychosocial support

Core (disaster health); focal area (behavioral health); for educators/

Iowa 2004 Mental health competencies for health care providers for terrorism and emergency preparedness and response [34]

Everly 2008 On academics: training for disaster response personnel: the development of proposed core competencies in disaster mental health [16]

IASC 2010 Mental Health and Psychosocial Support in Humanitarian Emergencies: What Should Humanitarian Health Actors Know? [35]

Flynn 2012

Provides disaster health educators and trainers throughout the health professions with

Mental health

Focus

Audiencea

Competency sets in which mental health is the primary focus

Competency set

Table 2

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a

Classification scheme from Walsh et al. [21•]

Profession (generalist nurses), focal area (mental health)

Mental health competencies applicable to generalist nurses. The focus is not on disasters, though competencies specific to disasters are included

Guidance to states in planning, designing, and implementing culturally competent mental health services for disaster survivors

Profession (mental health care providers, disaster health planners) focal area (cultural competence)

practices [37]. Each objective is keyed to previously published consensus-based competencies [22] •Definition and background of behavioral health •Differences when practicing a disaster environment •Partners and their roles •Individual and group responses to disasters •Cultural considerations •Special needs •Mental health care, assessment, diagnosis, intervention, and treatment •Crisis and risk communication •Caring for disaster workers •Knowledge of the referral options and available supports (e.g., protection agencies/ networks, community/social services, community support systems, legal services) offering protection and/or social support for social problems such as domestic violence and rape •Communication skills (e.g., active listening, respectful attitude) •Problem-solving •Psychological first aid (PFA) •Counseling of people recently exposed to trauma •PFA concepts (initial contact, rapport building, and stabilization) •Brief assessment, triage, intervention, referral, advocacy •Responder self-awareness and self-care •Provides 9 guiding principles of cultural competence •Knowledge, skills, and attributes of cultural competence •Key concepts of disaster mental health •A cultural competence self-assessment for disaster crisis counseling programs •Cultural considerations: norms, values, beliefs, behaviors, languages, family structures, socioeconomic status, and education •Mental health needs in disasters •Protecting vulnerable populations in disasters •Conduct environmental exposure history including exposure to psychological trauma •PFA •Crisis communication techniques with disaster survivors and disaster workers

Mental health

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AAN 2012 Essential Psychiatric, Mental Health and Substance Use Competencies for the Registered Nurse [41]

Under auspices of CDC and ASPH, develop PFA competencies for all disaster responders to support mental health needs of victims and responders

Core (disaster health and lay responders); focal area (mental health)

McCabe 2014 Psychological First Aid: a ConsensusDerived, Empirically Supported, Competency-Based Training Model [39] DHHS 2003 Developing Cultural Competence in Disaster Mental Health Programs: Guiding Principles and Recommendations [40]

Guidelines have been developed to assist health care providers in understanding the effects of disaster-related stress and for managing response in international humanitarian response efforts

curriculum recommendations, learning objectives, topics, and resources for disaster behavioral health education. Discusses interrelationship between research, services, and training

Focus

Core (international humanitarian health providers) focal area (mental health)

trainers of disaster health professionals

Audiencea

WHO 2012 Assessing Mental Health and Psychosocial Needs and Resources: Toolkit for Humanitarian Settings [38••].

Curriculum recommendations for disaster health professionals: disaster behavioral health [36••].

Competency set

Table 2 (continued)

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assessment, triage, intervention, treatment, referral, and advocacy; and dealing with substance abuse and severe mental illness.

Discussion It appears from the competencies identified in this study that although a wealth of competency sets for disaster health workers in general and a variety of specific professions [21•] have emerged in the post 9/11 era, competency sets specifically for disaster mental health professionals are lacking. Only one set of disaster mental health competencies was found that is directed toward mental health professionals [40], and it focused only on cultural competence. Disaster mental health competencies are either broadly written at a core level for all disaster health workers or are geared toward professions other than mental health professions, such as public health or nursing. Teams of multidisciplinary responders need members who possess a variety of disaster mental health competencies appropriate for each member’s discipline, as well as crosscutting competencies, such as those having to do with safety and functioning within an incident command structure [41]. Mental health professionals, of course, require the most specialized mental health competencies, such as diagnosis and treatment of post-disaster psychiatric disorders, differentiation of psychopathology from other emotional distress, and directing psychosocial interventions to distressed individuals without post-disaster psychopathology. Other disaster health team members need general mental health competencies such as managing medical conditions in the context of acute emotional distress in a post-disaster setting. All disaster workers, including non-health professionals, should possess basic mental health competencies such as skills in psychological first aid. Collectively, the existing disaster mental health competency sets present many essential competencies, and in doing so, they significantly advance the field of disaster mental health and the broader discipline of disaster health. A major purpose in creating the existing disaster mental health competency sets was to gain a broad consensus as to the requirements for workforce education and training. With regard to the general disaster health workforce, this purpose has been considerably advanced, keeping in mind that ongoing improvement and revision of the competency sets will be needed as they are put to use in response to an Bever-evolving list of public health threats^ [2] that may require new response capabilities. A next step should be the development and validation of a comprehensive set of competencies specifically for mental health professionals working in disasters. To enable validation, these competencies should, ideally, be criterion-based, i.e., they should predict actual performance based on

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identified performance criteria and standards. Consensusbased approaches to competency definition have inherent limitations of validity in that, although the competencies represent a wide group of experts’ opinions, there is little direct evidence of how such competencies relate to actual performance in a disaster. Face validity of the content is insufficient to serve as evidence that these competencies would necessarily result in, or predict, effective performance [4, 5, 8]. Consensus methods of competency definition also tend to operate from the somewhat limited conceptualization of competencies as knowledge, skills, and perhaps certain attitudes. Competencies for roles as complex as disaster health and disaster mental health are multidimensional, including trainable knowledge and skills, but also including personal characteristics such as self-concept, motivation, and traits. Prior studies [6, 10] have demonstrated that experienced emergency responders and leaders consider a number of personal traits, such as flexibility, adaptability, patience, and a sense of humor, as differentiating the more effective performers in actual disasters. Those who use the competency sets primarily for education and training may not find this limitation too severe, as such attributes are difficult to instill through training. A number of other competency-based workforce development processes, however, such as job design and description, recruitment, assessment, hiring, compensation, performance management, and career development, for which competencies focused on knowledge and skills alone are inadequate, can benefit from applying a more inclusive model of competencies. The existing disaster mental health competency sets will need to be augmented if they are to be made useful for such purposes.

Conclusions The competency sets identified in this study represent significant progress toward determining the relevant disaster mental and behavioral health knowledge and skills that can guide disaster health workforce planning in support of core preparedness and response capabilities. These competency sets provide a useful starting point for educators in designing and developing curricula and instructional activities for disaster mental health. They also can serve as a learning guide for disaster health workers who wish to acquire and maintain disaster mental health competencies. Instructional objectives have been written and corresponding learning resources identified for disaster mental health [36••], and these objectives have been linked to existing core disaster health competencies [22]. Such curriculum development efforts could be strengthened, however, by having a comprehensive set of competencies specific to disaster mental health on which to base curricula. Competency-based disaster mental health curricula are essential to the nation’s disaster preparedness and are needed

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to support the international call for professionalization among aid workers, a setting where mental health casualties dominate the health morbidity outcomes [42]. Future efforts to define disaster mental health competencies specifically for mental health professionals may benefit from studying the characteristics of identified superior performers using appropriate methods [4, 8]. It has been observed that people tend to agree more readily on who is outstanding than on what makes them outstanding [8]. If performance criteria are first identified to define what is meant by outstanding performance and how it is to be measured, then superior performers can be identified based on those criteria. In-depth studies of such performers can yield competencies with both criterion validity and predictive validity. In developing criterion-based competencies for disaster mental health professionals, consideration should be given to the requirements of both domestic and international disaster response efforts.

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Compliance with Ethics Guidelines Conflict of Interest Richard V. King, Frederick M. Burkle, Jr., Lauren E. Walsh, and Carol S. North declare that they have no conflict of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

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Page 9 of 9 14 support in humanitarian emergencies: what should humanitarian health actors know? Geneva, Switzerland 2010. 36.•• Flynn BW, Morganstein JC. Curriculum recommendations for disaster health professionals: disaster behavioral health. Janu ary 201 4; http:/ /ncdmph.u suhs.ed u/Documents/ BehavioralHealthRecommendations-201401.pdf. Accessed July 27, 2014. This report provides disaster health educators with detailed disaster behavioral health curriculum recommendations, including learning objectives, topics, and resources. The curriculum recommendations are linked to the previous work of consensus-based core competencies presented in Walsh et. al. (2012). 37. National Institute of Mental Health. Mental health and mass violence: evidence-based early psychological intervention for victims/ survivors of mass violence. A workshop to reach consensus on best practices. Washington, D.C. 2002. 38.•• World Health Organization & United Nations High Commissioner for Refugees. Assessing mental health and psychosocial needs and resources: toolkit for humanitarian settings. Geneva: WHO; 2012. This report offers guidance to humanitarian public health workers in assessing needs for various mental health and psycho-social support (MHPSS) services to be provided within a multi-layered system of care. Twelve assessment tools are included. Although not a competency set, readers may gain insights to the varied contexts in which competent humanitarian workers must operate. 39. McCabe OL, Everly GS, Jr., Brown LM, et al. Psychological first aid: a consensus-derived, empirically supported, competency-based training model. American Journal of Public Health. Jul 18 2013. 40. U.S. Department of Health and Human Services. Developing cultural competence in disaster mental health programs: guiding principles and recommendations. Rockville, Maryland: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; 2003. 41. Psychiatric Mental Health Substance Abuse Essential Competencies Taskforce of the American Academy of Nursing Psychiatric Mental Health Substance Abuse Expert Panel. Essential psychiatric, mental health and substance use competencies for the registered nurse. Arch Psychiatr Nurs. 2012;26(2): 80–110. 42. Burkle FM. Conversations in disaster medicine and public health: the profession. Disaster Med Public Health Prep. 2014;8(1):5–11.

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